Status exploration and analysis of regional hospice and palliative care networks in Germany: A protocol for a mixed-methods study

Background Multi-professional cooperation between healthcare providers is a key quality criterion of hospice and palliative care. While hospice and palliative care networks can support cooperation on a local level, opportunities for wider cooperation through the establishment and development of regional hospice and palliative care networks in Germany have not yet been explored systematically. Aims The HOPAN study aims at: (1) identifying regional hospice and palliative care networks in Germany, (2) analysing these networks using an adapted quality assessment tool, and (3) proposing setting-sensitive recommendations for network development and exploring the benefits of these recommendations. Methods HOPAN is a prospective, observational, mixed-methods study comprising three work packages (WPs). In WP1, the stock of regional hospice and palliative care networks in Germany will be identified via database, literature, and internet research. In WP2a, focus groups will be conducted to adapt an existing maturity model for healthcare networks to regional hospice and palliative care networks. In WP2b, a questionnaire will be sent to each identified regional hospice and palliative care network to gain insight into their structure and status of development. In WP2c, group discussions will be conducted to develop setting-sensitive recommendations for these networks. Finally, in WP3, these recommendations will be sent to all participating hospice and palliative care networks, and the benefits of the recommendations will be evaluated via a questionnaire. Discussion Empirically developed setting-sensitive recommendations should enable the systematic establishment and management of regional hospice and palliative care networks in Germany, considering the specific needs and potential of each network. The study findings are expected to improve the overall development of hospice and palliative care services. Trial registration The study was prospectively registered in the German Clinical Trials Register (Deutsches Register Klinischer Studien) (Registration N° DRKS00030629; date of registration: 02 November 2022). The study is searchable under the International Clinical Trials Registry Platform Search Portal of the World Health Organization, under the German Clinical Trials Register number.


Background
Multi-professional cooperation between healthcare providers is a key quality criterion of hospice and palliative care. While hospice and palliative care networks can support cooperation on a local level, opportunities for wider cooperation through the establishment and development of regional hospice and palliative care networks in Germany have not yet been explored systematically.

Aims
The HOPAN study aims at: (1) identifying regional hospice and palliative care networks in Germany, (2) analysing these networks using an adapted quality assessment tool, and (3) proposing setting-sensitive recommendations for network development and exploring the benefits of these recommendations.

Methods
HOPAN is a prospective, observational, mixed-methods study comprising three work packages (WPs). In WP1, the stock of regional hospice and palliative care networks in Germany will be identified via database, literature, and internet research. In WP2a, focus groups will be conducted to adapt an existing maturity model for healthcare networks to regional hospice and palliative care networks. In WP2b, a questionnaire will be sent to each identified regional hospice and palliative care network to gain insight into their structure and status of development. In WP2c, group discussions will be conducted to develop setting-sensitive recommendations for these networks. Finally, in WP3, these recommendations will be sent to all participating hospice and palliative care networks, and the benefits of the recommendations will be evaluated via a questionnaire.

Discussion
Empirically developed setting-sensitive recommendations should enable the systematic establishment and management of regional hospice and palliative care networks in Germany, considering the specific needs and potential of each network. The study findings are expected to improve the overall development of hospice and palliative care services.

Trial registration
The study was prospectively registered in the German Clinical Trials Register (Deutsches Register Klinischer Studien) ( N/A -the protocol does not report results

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Title 1 Status exploration and analysis of regional hospice and palliative care networks in Germany: A 2 protocol for a mixed-methods study 3 The study "HOPAN -Status exploration and analysis of regional hospice and palliative care networks 17 using an adapted quality assessment tool" is funded (on the basis of peer review) by the Innovation 18 Fund of the German Federal Joint Committee (G-BA) (Grant N° 01VSF22042). The funding body was 19 not involved in the study design, the preparation of this paper, or the decision to submit the paper 20 for publication. The funding body will not be involved in the collection, analysis, or interpretation of 21 the study data. The funding body has reviewed this study protocol. 22

Competing interests 23
The authors declare that they have no competing interests. 24

Data availability 25
Data sharing is not applicable to this article, as no datasets have yet been generated or analysed for 26 the current study. 27 28

Abstract 29
Background 30 Multi-professional cooperation between healthcare providers is a key quality criterion of hospice and 31 palliative care. While hospice and palliative care networks can support cooperation on a local level, 32 opportunities for wider cooperation through the establishment and development of regional hospice 33 and palliative care networks in Germany have not yet been explored systematically. 34

Aims 35
The HOPAN study aims at: (1) identifying regional hospice and palliative care networks in Germany, 36 (2) analysing these networks using an adapted quality assessment tool, and (3) proposing setting-37 sensitive recommendations for network development and exploring the benefits of these 38

recommendations. 39
Methods 40 HOPAN is a prospective, observational, mixed-methods study comprising three work packages (WPs). 41 In WP1, the stock of regional hospice and palliative care networks in Germany will be identified via 42 database, literature, and internet research. In WP2a, focus groups will be conducted to adapt an 43 existing maturity model for healthcare networks to regional hospice and palliative care networks. In 44 WP2b, a questionnaire will be sent to each identified regional hospice and palliative care network to 45 gain insight into their structure and status of development. In WP2c, group discussions will be 46 conducted to develop setting-sensitive recommendations for these networks. Finally, in WP3, these 47 recommendations will be sent to all participating hospice and palliative care networks, and the 48 benefits of the recommendations will be evaluated via a questionnaire. 49

Discussion 50
Introduction 60 Until recently, some federal states in Germany promoted hospice and palliative care networks on a 61 voluntary basis; however, most networks were financed by the donations and fees of network 62 members (3-7). To improve on this situation, in 2021, the German legislature passed a new law 63 (Gesetz zur Weiterentwicklung der Gesundheitsversorgung/GVWG) providing for the promotion of 64 regional hospice and palliative networks (1). The aim of this legislation is to improve multi-65 professional and cross-sectoral cooperation in hospice and palliative care at a regional level, via 66 network coordinators, funded by statutory health insurance (8). Specifically, coordinators are tasked 67 to: (a) support cooperation and coordination between network members, (b) support joint public 68 relations, (c) initiate and organise further and advanced training programmes, (d) organise regular 69 network meetings, and (e) cooperate with other regional counselling services (2). 70 A comprehensive overview of regional hospice and palliative care networks in Germany is lacking. To 71 date, only two smaller surveys at the level of individual federal states have been conducted (5, 7). 72 One study published regional recommendations for the implementation and coordination of hospice 73 and palliative care networks (9), showing that the investigated networks differed considerably 74 regarding their stages of development, organisational structures, fields of activity and working 75 methods (6). 76 In hospice and palliative care, healthcare providers and volunteers must collaborate to improve the 77 quality of life of patients and their families (10). Cooperation between providers in care networks 78 enables a seamless interplay of all healthcare professionals and volunteers, thereby improving the 79 continuity of patient care (11, 12). 80 On a regional level, collaboration between healthcare providers in hospice and palliative care seems 81 to positively impact individual casework (13). According to the literature, regional networks may 82 increase the number of personal meetings between healthcare providers and increase members' 83 willingness to cooperate (14). Hence, regional networks may improve inter-professional 84 communication among healthcare providers, evoke confidence in action, reduce stress among 85 employees, ensure the early integration of psychosocial and spiritual support, and reduce the 86 number of hospital admissions (15). They may also promote joint initiatives for the further 87 development of local hospice and palliative care services and improve the organisation of patient-88 centred care (13,14). 89 Until recently, the establishment and development of regional hospice and palliative care networks 90 in Germany was largely unsystematic. These networks were not integrated into the German 91 healthcare system and structural standards and quality indices for network collaboration and 92 coordination were lacking. 93

Study aim 95
The project "HOPAN -Status exploration and analysis of regional hospice and palliative care 96 networks using an adapted quality assessment tool" has the following three objectives: 97 (1) to identify regional hospice and palliative care networks in Germany, 98 (2) to analyse these networks using an adapted quality assessment tool, and 99 (3) to propose setting-sensitive recommendations for further network development and to explore 100 the benefits of these recommendations. 101 Design 102 HOPAN is a prospective, observational, mixed-methods study organised into three working packages 103 (WPs). The study protocol adheres to STROBE guidelines (13). WP1 will involve the identification of 104 regional hospice and palliative care networks in Germany via database, literature and internet 105 research. The findings will provide an overview of the number and regional distribution of hospice 106 and palliative networks in Germany. 107 In WP2a, an existing maturity model for healthcare networks, developed within the INDiGeR 108 research project, will be adapted to accommodate the structures and contents of the identified 109 regional hospice and palliative care networks (18) The maturity model focuses on the common provision of services from a single network perspective. 118 This methodological tool will be adapted for application to hospice and palliative networks. 119 In WP2a, a group of experts will be formed on the basis of the survey results (WP1) with the leaders 120 (e.g. coordinators, moderators) of hospice and palliative care networks in Germany and other 121 network experts. Expert group workshops will examine the extent to which the maturity model 122 should be supplemented and modified to accommodate hospice and palliative care networks, and 123 how the four relevant network dimensions (i.e. infrastructure, moderation, governance, promotion) 124 should be specified and operationalised. This specified and adapted maturity model will form the 125 basis for the model-based network analysis in WP2b. 126 In WP2b, the adopted maturity model for regional hospice and palliative care networks will be 127 operationalised into questionnaire items. Subsequently, an online survey will be administered to all 128 of the identified networks. The survey is expected to comprise three sections: 129 (a) A general section on the networks' basic and structural data (e.g. year of founding, number of 130 partners, participating care actors, number of meetings per year). 131 (b) A specific section on the model-based network evaluation, focussing on network dimensions and 132 the degrees identified in WP2a (e.g. for network moderation: role understanding and responsibility, 133 intensity of cooperation, communication, services offered to network members, network culture). 134 Specific items will be associated with each sub-dimension, graded in four levels (e.g. initial, 135 structured, established, optimised). Based on the results, a developmental status will be assigned to 136 In WP2c, four expert workshops with the abovementioned network leaders and coordinators (n=10) 141 will be conducted to develop setting-sensitive recommendations for regional hospice and palliative 142 care networks, on the basis of the results from WP2b. 143 In WP3, the recommendations arising out of WP2c will be disseminated to individual networks and 144 usability will be evaluated. Each network surveyed in WP2b will receive setting-sensitive, individual 145 recommendations, according to the network's maturity level. Additionally, each network will receive 146 a link to a quantitative, standardised, online questionnaire to evaluate the utility of the 147 recommendations. This questionnaire will be developed a priori by the research team and will 148 contain questions on the usefulness of the recommendations in their respective dimensions, as well 149 as the actual and planned implementation of the recommendations. The link to the online 150 questionnaire will be sent to the networks using the survey software SoSciSurvey (SoSci Survey GmbH, 2006GmbH, -2022. The primary aim will be to explore the relevance and feasibility of the setting-152 sensitive recommendations. Finally, the maturity model and its level-specific recommendations will 153 be adapted in accordance with the survey results and prepared for regional hospice and palliative 154 care networks, so it can be used by: (a) further regional hospices and networks for the purpose of 155 self-assessment and (b) health insurance providers for the purposes of quality assessment and 156 reporting. 157 158 Figure 2: HOPAN study design 159

Study population and data collection 160
In WP1, all regional hospice and palliative care networks in Germany will be identified as completely 161 as possible. The total stock of such networks in Germany is currently unknown. Hence, the size of this 162 population can only be estimated. Based on the identified hospice and palliative care networks in 163 Lower Saxony (19) and Bavaria (20), a total of 150 networks in Germany is estimated. Data will be 164 collected via internet and literature research, supplemented by a search of national databases, such 165 as the publicly accessible palliative care portal [12], the "Wegweiser Hospiz-und Palliativversorgung 166 Deutschland" [37], and partly available lists of health ministries and state coordination offices [14]. 167 Network names, contact details, regions, and other relevant and available information (e.g. year of 168 founding, legal formation, sponsorship) will be recorded. 169 The group of experts, which will be set up in WP2a, will include leaders (n=10; e.g. coordinators, 170 moderators) of hospice and palliative care networks in Germany and other network experts from 171 hospice and palliative care facilities in Germany. Participating network leaders (n=7-8) will be 172 selected from the group of networks identified in WP1. The selection will follow the maximum 173 variation sampling strategy, based on criteria that have not yet been defined (e.g. size, duration of 174 existence, degree of professionalisation). Moreover, a small number of experts (n=2-3) will be 175 recruited from the group of network members, based on the suggestions of cooperating German 176 professional hospice and palliative care associations. If experts decline to participate in the study, the 177 expert group will be supplemented on the basis of the same sampling criteria. 178 A total of n=5 expert workshops are planned, each involving n=10 of the abovementioned leaders 179 and coordinators. Four of these meetings will be conducted as online video conferences. The first 180 workshop will explore the extent to which the structure of the INDiGeR maturity model should be 181 augmented and modified to accommodate hospice and palliative care networks. Members of the 182 research team will send literature on the maturity model to participants prior to the workshop, and 183 then present the model to participants at the workshop. The subsequent three workshops will aim at 184 concretising and operationalising the assumed relevant network dimensions (i.e. infrastructure, 185 moderation, governance, promotion) for regional hospice and palliative care networks. The 186 documented results of the workshops will be compiled, reflected upon, discussed, and integrated by 187 the research team and further developed into a maturity model for regional hospice and palliative 188 care networks. The developed model will then be presented to the experts for their feedback in a 189 further online workshop. In the expert workshops, established methods for moderating group 190 discussions (e.g. card queries, World Cafe) will be used. Each workshop will be 3 hours in duration, 191 and will be audio recorded and transcribed verbatim. 192 In WP2b, the respective leaders/coordinators of an estimated n=150 hospice and palliative care 193 networks will be sent an online survey. A response rate of 70% is expected, and thus n=105 valid data 194 sets to include in the analysis. Notwithstanding this calculated response rate, the aim will be to 195 include as many as possible of the networks identified in WP1, in order to increase statistical power, 196 especially for the more detailed network analysis. 197 In WP2c, expert workshops (n=4) with the abovementioned network leaders/coordinators (n=10) will 198 be conducted to develop setting-sensitive recommendations for regional hospice and palliative care 199 networks. For this purpose, the results of the network analysis for the individual dimensions of the 200 maturity model (including the level-specific locations of the networks) will be presented as impulse 201 speech. In group discussions, participants will develop specific recommendations for the further 202 development of networks for each development level and sub-dimension. Each workshop will be 3 203 hours in duration, and will be audio recorded and transcribed verbatim. An overlap of participants in 204 WP2a and WP2c will promote participants' long-term commitment to and identification with the 205 project. 206 In WP3, all networks that participated in WP2b will be administered a quantitative online survey. A 207 total of n=105 participating networks in WP2b and a response rate of 70% are assumed. Hence, 74 208 valid data sets are expected for inclusion in the analysis. Respondents will indicate on a 4-point 209 verbal rating scale the extent to which they deem the individual recommendations relevant and 210 feasible for their own network. They will also be afforded the opportunity to make suggestions for 211 improvement, via free text comments. 212

Inclusion and exclusion criteria 213
WP2a and WP2c will include leaders (e.g., coordinators, moderators) of hospice and palliative care 214 networks in Germany and other network experts from the field of hospice and palliative care in 215 Germany. All participants will be aged ≥18 years and have theoretical and/or practical knowledge 216 and/or experience of hospice and palliative care networks in Germany. 217 After receiving detailed information about the type, content, and purpose of the study and their 218 participation, experts will provide written informed consent to participate. Experts of all genders and 219 ethnic backgrounds will be invited to participate. 220 Experts will be excluded from the study if they are insufficiently proficient in the German language to 221 join group discussions and/or if they do not consent to participate. 222

Ethical considerations 223
The study was approved on 20 August 2022 by the Ethics Committee of Hannover Medical School (N° 224 10424_BO_S_2022) and the appointed data protection officer of Hannover Medical School. Prior to 225 administering the questionnaire, the researchers will provide eligible participants with detailed 226 information about the study type, content, purpose, and duration. 227 All study participants will be informed in detail, orally and in writing, about the project aims and 228 expected outputs, before confirming their participation in the project. Participation will only be 229 possible when the individual explicitly agrees to participate in the study and signs a written consent 230 form. Each participant will have the right to refuse or discontinue participation at any time without 231 providing any reasons for doing so. 232 The study results (e.g. transcripts) will be stored pseudonymously on the secure servers of the MHH, 233 in order to ensure personal data protection and prevent the results from being linked to individual 234 participants. 235

Data analysis 236
The data analysis will aim at describing the current stock of regional hospice and palliative care 237 networks in Germany and determining setting-sensitive recommendations for the further 238 development of these structures. 239 In WP1, data from the national database, internet, and literature searches will be transferred to a 240 13 documented in a template, according to availability (e.g. network name, district, federal state, 242 contact person, contact address, legal formation, year of founding, region [urban/rural], and number 243 of members). Additionally, quantitative data will be analysed descriptively using IBM SPSS Statistics 244 27 (SPSS Inc., Chicago, IL, USA) for Windows. The survey will provide an overview of the number and 245 regional distribution of hospice and palliative care networks in Germany. 246 In WP2a, the expert workshops (n=5) with n=10 participants (each) will be audio recorded and 247 transcribed verbatim. Visual data, including the findings of card queries and World Cafes, will be 248 photographed. Both oral and visual data will be analysed according to qualitative content analysis, 249 using MAXQDA 2022 (VERBI Software Consult Sozialforschung GmbH, 1989. 250 In WP2b, the results of the online survey will be analysed descriptively and with frequency tables, 251 using IBM SPSS Statistics 27. If possible, cluster analyses will be conducted to identify similar 252 structures and different network types (e.g. "public/outward-oriented networks" vs. 253 "member/inward-oriented networks"). Free text answers regarding network management will be 254 inductively categorised, summarised, and evaluated using frequency counting. 255 In WP2c, the transcripts of the expert group discussions will be analysed according to qualitative 256 content analysis, using MAXQDA 2022. A deductive coding procedure will be used, whereby the 257 levels and sub-dimensions of the maturity model specified in WP2a will function as categories. The 258 research team will review the recommendations in terms of coherence and adapt the wording as 259 needed. 260 In WP3, quantitative data from the online survey will be analysed descriptively, using IBM SPSS 261 Statistics 27. Free text comments will be analysed descriptively, in terms of content. 262 Figure 2 provides an overview of the mixed-methods study design across the three WPs. The figure  263 illustrates the methods that will be used to develop setting-sensitive recommendations for regional 264 hospice and palliative care networks in Germany. 265

Expected results 266
The main expected results are: (1) an overview of existing regional hospice and palliative care 267 networks in Germany, (2) a maturity model for regional hospice and palliative care networks, (3) a 268 model-based network analysis, and (4) setting-sensitive recommendations for the further 269 development of each network. These findings will contribute to the further development of hospice 270 and palliative care services in Germany, on a wider scale. 271

Study risks 272
Access to experts and leaders/coordinators of hospice and palliative care networks can be difficult, 273 depending on their workloads and basic attitudes towards and experience with research projects. 274 Hence, reaching the required number of participants may be a methodological challenge. However, 275 achievement of the case numbers seems feasible, since the majority of the WPs involving 276 leaders/coordinators are based on a qualitative research design, and the case numbers were 277 calculated generously. Also, recruitment will be broad. 278 For the nationwide identification of regional hospice and palliative care networks, cooperative 279 agreements will be made with all of the relevant associations, ensuring access to the relevant 280 databases ("Wegweiser Hospiz-und Palliativversorgung" [37]) and network coordinators. In addition, 281 the status analysis will be supplemented by an independent internet search for each federal state. 282 This staggered procedure will ensure that networks are comprehensively identified and addressed. 283 Furthermore, it is expected that the networks will have an intrinsic interest in participating in the 284 project, in order to benefit from the specific recommendations for network development. 285

Study status and timeline 286
The HOPAN study is scheduled to start in January 2023, spanning 2 years. 287 Discussion 288

Limitations of the study design 289
The HOPAN study will use a broad research strategy to identify regional hospice and palliative care 290 networks in Germany. However, since new funding opportunities for hospice and palliative care 291 networks were established in April 2022, it is expected that further networks will emerge during the 292 course of the study. The research team will ask all partners to inform them of all emerging networks, 293 in order for these networks to be invited to participate in the study. Nonetheless, a complete survey 294 of all existing networks cannot be guaranteed. 295 The network analysis will be based on qualitative and quantitative data collected from network 296 coordinators and leaders. Thus, the HOPAN study will specifically reflect the perspectives of these 297 network coordinators and leaders, while omitting the perspectives of other network members, as 298 well as patients and family caregivers. Hence, the study will not be able to evaluate the impact of 299 hospice and palliative care networks on the quality of patient care. 300

Dissemination and implementation 301
To promote the accessibility and longevity of the research data and results, the research team will 302 report the study findings in a comprehensive and transparent manner. Regardless of the findings, the 303 research team will produce national and international congress presentations and peer-reviewed 304 publications (published as open access, where possible). Data files with no personal identifying 305 information will be kept after the study completion. In accordance with the American Psychological 306 Association Code of Ethics, Sec. 8.14, "Sharing Research Data for Verification" [38], the study leader 307 will not withhold any unidentifiable data from other researchers who wish to verify the conclusions 308 of the author(s). Researchers who wish to use HOPAN study data to answer new research questions 309 must obtain prior permission from the research group and author(s). 310

311
The results may be used directly by eligible networks in Germany (of which there are approximately 312 400) to improve their network structure and work. Based on the level-specific recommendations, each network will receive suggestions for further development and optimisation, tailored to the 314 individual network status, thus enabling a process-oriented network development geared towards 315 regional structures. The specified maturity model will ensure that all relevant network dimensions 316 are considered. The recommendations are expected to support network coordinators' efforts to 317 specify their field of activity, and to be used for training and the further education of network leaders 318 and coordinators in hospice and palliative care. The project results may also be used for quality 319 assessment and quality management in regional hospice and palliative care networks. 320

Conclusion 321
The present study protocol explains the purpose, significance, and scope of the mixed-methods study 322 HOPAN, as well as its study design. The recommendations developed in this study are expected to 323 optimise the establishment and development of regional hospice and palliative care networks in 324 Germany, by ensuring better network coordination and promoting the development of regional 325 hospice and palliative care structures. This improved networking is likely to have a positive effect on 326 the quality of care in hospice and palliative care. The adapted maturity model will be initially 327 published in digital form. If necessary, the model will be further developed in a follow-up project into 328 a digital self-assessment tool for networks, which will automatically show level-specific 329 recommendations relevant to the self-location. In addition, the status analysis and maturity model 330 may be used in the longer term as evaluation tools (e.g. by health insurance providers to fulfil their 331 reporting obligations to the Federal Ministry of Health). 332 The aim of publishing the present study protocol is to promote transparency by facilitating open 333 access to comprehensive study details that extend beyond the summary publicised in the German 334 Clinical Trials Register. Moreover, the study protocol may serve as a point of reference to the 335 scientific community and other parties interested in the scientific and ethical aspects of the study, 336 and prevent unnecessary duplication. 337 338

Author contributions 339
SvS, CB, FAH, TS, SSt, and NSch developed the original study plan, wrote the grant application, and 340 obtained funding. SvS developed the manuscript on the basis of the original German grant 341 application. CB, FAH, TS, SSt, and NSch enhanced the quality of the draft manuscript by revising it 342 critically. All authors read and approved the final manuscript. 343